Subcontractor Form

Company Name

Contact Person

Email

Phone

Company Address

Type of Work Performed

% of Work Self Performed

Business Enterprise Type

Years in Business Under Present Name

Volume of Work Presently Under Contract

Years Experience Performing Trade

Average Volume Past 3 Years

Surety Company

Agent Company

Agent Name

Agent Phone Number

Your Single Bonding Capacity

Your Aggregate Bonding Capacity

Bank Name

Bank Contact with Title

Address

Phone

Workers Compensation EMR for the last (3) years: 2018: 2019: 2020:

Have you had any OSHA fines within the last (3) years?

Yes No

Have you had any job site fatalities within the last (3) years?

Yes No

If you answer yes to either of the above questions, you must submit on a separate sheet the details describing the circumstances surrounding each incident.

Please submit (3) references which may include owners, general contractors or construction managers.

I hereby certify that this information is true and complete, to the best of my knowledge.

Subcontractor Form

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